Failure to Provide Wound Care per Physician Orders and Document Accurately
Penalty
Summary
The facility failed to provide wound care according to physician's orders for two residents with non-pressure related skin conditions. One resident with dementia, type two diabetes, and varicose veins was observed with dirty and unkempt kerlex bandages on both ankles, dated six days prior, despite orders for daily dressing changes. The resident was unable to recall the reason for the bandages or the frequency of changes. Record review confirmed that staff had documented daily dressing changes, but observation indicated this was not done as ordered. Another resident with venous insufficiency, type two diabetes, and chronic pain was found with a left foot wound wrapped in undated kerlex and ace wrap, emitting a strong odor. The resident, who was cognitively intact, reported that the dressing had not been changed for several days, although daily changes with a specific solution were ordered. Staff documentation indicated treatments were completed, but physical evidence and resident interview contradicted this. Facility leadership confirmed that dressings should be dated and changed as ordered, but could not explain the discrepancies in documentation and care.
Plan Of Correction
F 684 1.) Resident #6 and #13 were re-assessed by the wound nurse and no acute issues noted. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all dressing changes were completed as ordered. Licensed nurses were re-educated on completing dressings as ordered. 3.) System change: the nurse managers during rounds will spot check wound care dressings to ensure they are completed as ordered. 4.) The DON/Designee will observe 5 dressing changes weekly x 12 weeks then monthly x 3 months to ensure they are completed as ordered. Any nonadherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing and sustained compliance.